*Please note that MVMC staff are unable to dispense ANY medication due to our liability insurance.

Please rank your child’s ability to swim on a scale of 1-10 with 1 being unable to swim and 10 being a strong swimmer.*

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Name of your health insurance provider (If none, please write none.)

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Health Insurance Policy Number

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Authorizations

Please read and initial the following releases. Include your signature at the bottom of the page.

PARENT AUTHORIZATION*

I hereby declare my child to be physically sound, having medical approval to participate in the activities of the Amigo-Amiguito Club. This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted. I further understand that neither the Multicultural Center nor any of its paid staff or volunteers can be held responsible in the event of an accident. I also certify that my child is amenable to discipline and free from habits or attitudes which would make him / her an undesirable participant.Invalid Input

OFF MVMC GROUNDS AUTHORIZATION*

I authorize that my child has permission to go off St. Francis Episcopal Church grounds when necessary to participate in club activities, as some require the use of a facility or recreational area that is not available at the regular program site. I agree to hold neither the Multicultural Center nor any of its paid staff or volunteers responsible for any accident or injury that may occur while my child is participating in a club activity that is off St. Francis Episcopal Church grounds.Invalid Input

EMERGENCY AUTHORIZATION

I authorize any representative of the Multicultural Center to seek medical attention for my child when immediate medical care is warranted by the circumstances and I cannot be reached, or if under the circumstances there is not time to attempt to reach me because of the nature of the injury or illness. I further authorize the health care professional selected by the agency to provide the necessary care and treatment for my child.Invalid Input

PHOTOGRAPH / VIDEO AUTHORIZATION*

The Multicultural Center has my permission to use photographs / videos of my child in any promotional material. Invalid Input

STUDENT RELEASE*

In consideration of my child’s participation in the Multicultural Center activities, I do hereby agree to hold free from any and all liability the agency and its respective offices, employees, and members and do hereby for myself, my heirs, executors, and administrators, waive, release, and forever discharge any and all rights and claims for damages which I may have or which hereinafter accrues to me arising out of or connected with my child’s participation in any of the activities of the Multicultural Center.Invalid Input

Policies*

I have read, understood, and agree with the behavior policy, pick up policy, and attendance policy.Invalid Input